GROUP EVIDENCE OF

COVERAGE

LIBERTY Dental Plan of Florida, Inc.

This Evidence of Coverage provides the following information:

The advantages of your LIBERTY Dental Plan and how to use your

benefits

Eligibility requirements

Enrollment procedures

Reasons for Termination of Coverage

Grievance Procedures

Answers to your frequently asked questions

Please also refer to your Copayment Schedule and any applicable Benefit

Riders which are attached to the Evidence of Coverage. The Schedule and

applicable Riders detail the benefits available to you as well as Exclusions

and Limitations of coverage.

This Evidence of Coverage and Copayment Schedule will provide you with

the information you should know about your Dental Plan. It explains clearly

how it works and the many advantages LIBERTY Dental Plan provides you.

LIBERTY Dental Plan of Florida, Inc.

Amir Neshat, D.D.S.

President & CEO

LIBERTY Dental Plan of Florida, Inc. provides benefits as a Prepaid

Limited Health Service Organization as described in Chapter 636 of the

Florida Statutes.

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LDP.EOC – Group (09/09)

LIBERTY Dental Plan BENEFITS ARE EASY TO USE

Dental Benefits should be simple to use for you and your family. Our plans

offer comprehensive dental coverage without claim forms, prohibitive

deductibles, or restrictive annual maximums.

The difference with LIBERTY Dental Plan: good provider selection, clear

communication, and, most importantly, requiring the dentists to perform to

the standards of the participating contract they signed with the plan.

That is the difference in LIBERTY Dental Plan. We have open

communication and provide excellent support to our panel of Plan dentists.

Our goal is to provide you with the comprehensive dental benefits you

purchased. We pledge to support your choice of LIBERTY Dental Plan by

giving you confidence through the excellent customer service you deserve.

After all, isn’t that what it is all about?

At LIBERTY Dental Plan, you get quality dental benefits at a very

reasonable price.

THE LIBERTY Dental Plan ADVANTAGES

* No Claim Forms

* No Deductibles or Maximums

* Low Out-of-Pocket Costs

* Selection of Pre-screened Dentists & Specialists

* Multi-Lingual Provider Network

* Change Dentist Selection Any Time

* Orthodontic Coverage

* Most Pre-existing Conditions Covered

* Network Dentists Provide 24-hour Access to Emergency Care

* Toll-Free Member Assistance Lines

The hearing and speech impaired may use the Florida Relay Service

toll-free telephone numbers (800) 735-2929 (TTY) or (888) 877-5378

(TTY) to contact the department.

SECOND OPINION

At no cost to you, you may request a second dental opinion, when

appropriate, by directly contacting Member Services either by calling the

toll-free number (877) 877-1893 or by writing to: LIBERTY Dental Plan,

P.O. Box 26110, Santa Ana, CA 92799-6110. Your primary care dentist

may also request a second dental opinion on your behalf by submitting a

Standard Specialty or Orthodontic Referral Form with appropriate x-rays.

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All requests for a second dental opinion are approved by LIBERTY Dental

Plan within five (5) days of receipt of such request. Upon approval,

LIBERTY Dental Plan will make the appropriate second dental opinion

arrangements and advise the attending dentist of your concerns. You will

then be advised of the arrangement so an appointment can be scheduled.

Upon request, you may obtain a copy of LIBERTY Dental Plan’s policy

description for a second dental opinion.

YOUR DENTAL PLAN

LIBERTY Dental Plan has been providing and administering dental benefits

for over twenty-five (25) years. LIBERTY Dental Plan is in the on-going

process of enhancing our statewide panel of Plan dentists and specialists to

accommodate the needs of our Subscribers.

Our goal is to provide Floridians with appropriate dental benefits, delivered

by highly qualified dental professionals in a comfortable setting. All of

LIBERTY Dental Plan’s contracted private practice dentists have undergone

strict credentialing procedures, background checks and office evaluations. In

addition, each Plan dentist must adhere to strict contractual guidelines. All

dentists are pre-screened and reviewed on a regular basis. Our Provider

Relations Department conducts a quality assessment program which includes

ongoing contract management to assure compliance with continuing

education, accessibility for Members, appropriate diagnosis and treatment

planning. In addition, we conduct random surveys of Member groups to

evaluate their view of the dental plan overall. This includes both Primary

Care Dentists (General Dentists) and Specialists. Your Primary Care Dentist

will provide for all of your dental care needs, including referring you to a

specialist should it be necessary.

When you join LIBERTY Dental Plan, you must choose a Primary Care

Dentist. If you desire to make a change, you may do so at any time. (Please

note: Your request to change dentists will not be processed if you have an

outstanding balance with your current dentist.) Simply contact our Member

Services Department toll-free at (877) 877-1893 or submit a change request

in writing to: LIBERTY Dental Plan, P.O. Box 26110, Santa Ana, CA

92799-6110. Your requested change to a Primary Care Dentist will be in

effect on the first (1

) day of the following month if the change is received

by LIBERTY Dental Plan prior to the twentieth (20

) of the current month.

All services and benefits described in this publication are covered only if

provided by a contracted LIBERTY Dental Plan Primary Care Dentist or

Specialist. The only time you may receive care outside the network is for

emergency dental services as described herein under “Emergency Dental

Care.”

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ELIGIBILITY RULES

To be eligible to become a Subscriber a person must:

1. Be an active full-time employee, retired employee, or Member of the

Plan Sponsor as defined by the Plan Sponsor.

2. Have applied for Membership on enrollment forms supplied by the Plan

and submitted the applicable Premium, and

3. Reside or work within the Plan’s Service Area.

Eligible Dependents of the Subscriber includes the following individuals

only if they reside or work within the Plan’s Service Area:

1. The lawful spouse of the Subscriber.

2. Registered Domestic Partner;

3. The unmarried Dependent Child of a Subscriber, (or in the case of a

newborn child, the Dependent Child of the Subscriber’s covered

Dependents), up to the child’s nineteenth (19

) birthday, or up to

the child’s twenty-fourth (24

) birthday provided the dependent is a

full-time student at an accredited academic institution.

4. A Dependent Child who can be certified to the Plan as incapable of

self-sustaining employment by reason of mental retardation or

physical handicap and is chiefly dependent upon the Subscriber for

support and maintenance. Proof of such incapacity must be

furnished to the Plan by the Subscriber within thirty (30) days of the

request for such proof by the Plan. Recertification of such

incapacity may be required by the Plan, but not more frequently

than once annually.

Full-time student dependents who attend school outside the Plan’s Service

Area must travel back to the Plan’s Service Area to receive covered dental

services from Plan Providers. The only exception is for Emergency Dental

Care.

Dependents eligible at the time of the Subscriber’s initial enrollment but not

previously enrolled may be added to the Subscriber’s coverage only during

an open enrollment period. Subscribers wanting to add Dependents to his or

her coverage due to a change in status created by the following

circumstances must do so within thirty (30) days of the date the Dependent

becomes eligible:

1. Legal Spouse newly acquired as a result of marriage;

2. Registered Domestic Partner;

3. Other unmarried Dependents newly acquired as a result of marriage

or registered domestic partnership;

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4. Children who are legally adopted by the Subscriber pursuant to

Chapter 63, Florida Statutes, are considered Dependents from the

moment of permanent placement in the residence of the Subscriber,

or from the moment of birth if a written agreement to adopt such

child has been entered into by the Subscriber prior to the birth of the

child; or

5. Newborn children of the Subscriber or the Subscriber’s covered

Dependents are covered from the moment of birth.

Eligible Dependents must be enrolled by timely completing and submitting

an enrollment form to the Plan Sponsor along with the applicable Premium.

ENROLLMENT APPLICATION AND DATE OF ELIGIBILTY

Newly eligible Subscribers must complete The Plan approved enrollment

application available from Plan Sponsor within thirty (30) days of the date of

his/her eligibility to assure timely coverage. Eligible Subscribers who

choose not to elect coverage for themselves or any eligible Dependents must

complete and sign a Waiver of Coverage within thirty (30) days of initial

eligibility. A new Subscriber and any newly eligible Dependents who do not

complete an enrollment application (or waive coverage) within thirty (30)

days of initial eligibility, and requests coverage at a later date, will have to

wait until the next annual open enrollment period to apply for coverage.

All persons including the Subscriber and eligible Dependents who have

applied for Membership and for whom the appropriate Premium has been

paid prior to the 20

day of the month shall be eligible for Benefits

commencing on the 1

day of the following month. Should required

enrollment form(s) and Premium be received after the 20

day, eligibility

will commence on the 1

of the second following month.

OPEN ENROLLMENT

An annual open enrollment period of at least thirty (30) days each Contract

Year that this Group Contract is in effect, will be designated on a date agreed

upon by the Plan and the Plan Sponsor. During the annual open enrollment

period, eligible Subscribers who waived coverage, voluntarily terminated

coverage or did not elect coverage in a timely manner for him or herself and

any eligible family Members, may elect coverage during the annual open

enrollment period.

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EFFECTIVE DATE AND TERMINATION DATE

This Group Contract is effective on the date indicated on the Plan

Information Page. The coverage effective time and termination time for any

dates used is 12:01 A.M.

TERMINATION OF A MEMBER’S COVERAGE

Coverage for the Subscriber and each of his or her covered Dependents will

cease if the Subscriber’s affiliation with the Plan Sponsor is terminated for

any reason as set forth in this Group Contract. A Member shall not have

his/her coverage terminated under this Group Contract because of the

amount, variety or cost of services required by such Member.

Coverage for a Member will cease on the last day of the month for which

Premium is paid if coverage is terminated for any of the following reasons.

Except for non-payment of Premium, the Plan will give forty-five days

advance written notice of coverage termination:

1. Non-payment of Premium;

2. The Subscriber or Member ceases to be eligible for coverage for

any reason as set forth in this Group Contract;

3. the Member commits any action of fraud or material

misrepresentation in applying for or seeking any benefits under this

Contract;

4. for cause due to disruptive, unruly, abusive, unlawful, fraudulent or

uncooperative behavior towards a health care provider or

administrative staff that seriously impairs the Plan’s ability to

provide services to the Member and/or to other Members;

5. misuse of the documents provided as evidence of benefits available

pursuant to this Group Contract including the Member

Identification Card;

6. the Member furnishes incorrect or incomplete information for the

purpose of fraudulently obtaining services;

7. the Member leaves the Plan’s Service Area with the intention to

relocate or establish a new residence; or

8. a covered child dependent reaches the limiting age as specified in

the Eligibility Section of this Group Contract, or if a court order,

including a qualified medical child support order covering a

dependent is no longer in effect.

Prior to terminating a Member for cause, the Plan will document the

Member’s problem and make a reasonable effort to resolve the problem,

including the use or attempted use of the Plan’s Grievance Procedure. We

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will also to the extent possible, ascertain that the Member’s behavior is not

related to the use of services or mental illness.

EXTENSION OF BENEFITS

In the event this Group Contract is terminated for any reason, a Member is

entitled to continue services for a specific treatment or procedure that was

undertaken prior to termination. This extension of benefits will cease on the

earliest of completion of treatment or 90 days from the date the Group

Contract terminates.

It is the responsibility of the Plan Sponsor to notify each Subscriber of

termination of the Group Contract. During the period required for

completion of such procedures, each Member shall continue to pay Co-

payments directly to the Plan dentist, as required under the Benefit Schedule

and all exclusions and limitations will continue to apply during the

extension.

CONVERSION

A Member who has been continuously covered for at least three months

under this Group Contract, has the right to apply for a conversion plan if

coverage terminates due to:

1. Termination of employment;

2. Loss of coverage due to the termination of this Group Contract, if it

is not replaced by a similar plan within 31 days of termination.

A Subscriber’s dependents who are covered as dependents under this Group

Contract may also convert, but only as dependents of the Subscriber, not on

their own.

However, a Subscriber’s dependents who have been covered for 3

consecutive months before coverage ends may, on their own, convert to a

conversion plan under one of these following conditions:

1. If the Subscriber’s conversion coverage terminates, Covered

Dependents may convert as dependents under a new conversion

plan.

2. If the Subscriber dies, the covered spouse may convert.

3. If the Subscriber and the covered spouse die simultaneously or upon

the death of the last surviving parent, the covered children may

convert if they are of contracting age.

4. If the covered spouse is no longer a qualified family Member, the

spouse may convert.

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5. If a covered dependent child is no longer an eligible Dependent as

defined in this Group Contract, such dependent may convert.

A Member who is eligible for conversion may obtain conversion coverage

without having to submit evidence of health qualification. However, the

Member must apply in writing and pay the first annual premium for the

conversion plan within 31 days after his or her coverage under this Group

Contract terminates. The application form to be used, and information about

conversion benefits may be obtained by contacting the Plan.

If the Subscriber qualifies for federal COBRA continuation benefits,

conversion may take place at the end of the federal continuation period, if

written application is made and the first annual Premium payment is made

within 63 days of the date coverage under the continuation period ends.

Please consult with your Plan Sponsor regarding any applicable COBRA

rights.

Unless otherwise prohibited by law, conversion is not available if:

1. The Member has not been continuously covered for at least three

months under this Group Contract prior to termination of coverage;

2. Coverage under this Group Contract ends due to failure to pay any

required Premium;

3. This Group Contract is replaced by similar group coverage within

31 days of the termination date of this Group Contract;

4. The Member has left the Plan’s Service Area with the intent to

relocate or establish a new residence;

5. The Member is terminated for any reason set forth in the

Termination of a Member’s Coverage provision, except for a

dependent child reaching the limiting age.

WHAT IF I HAVE A QUESTION ABOUT MY DENTAL PLAN

LIBERTY Dental Plan provides toll-free telephone access to covered

Members. Just call our Member Services Department if you have a question

or inquiry. Our Member Service representatives will be glad to provide you

information or resolve your inquiry. Call (877) 877-1893, between the

hours of 8:00 a.m. to 5:00 p.m. (EST) Monday through Friday.

HOW DO I RECEIVE CARE

You must choose a Primary Care Dentist when you enroll in the plan. This

dentist will be responsible for providing the dental care needs for you and

your family, including referring you to a specialist should it be necessary

(you can change dentists at anytime by calling LIBERTY Dental Plan or by

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submitting a request for provider change in writing). A directory of Plan

dentists will be sent to you upon request or you can visit

www.libertydentalplan.com

You may select any LIBERTY Dental Plan contracted provider accepting

your plan. However, you may want to consider a choice convenient to your

residence or work. You and your entire family must use the same dentist.

As a Member, you should be able to make an appointment to be seen for

dental hygiene and routine care within three weeks of the date of your

request. This is based upon available schedule times.

HOW TO MAKE AN APPOINTMENT

After completing your enrollment form, you are eligible to receive care on

the first of the month following LIBERTY Dental Plan’s receipt of your

enrollment application, premium and notification of your eligibility by your

Plan Sponsor.

Be sure to identify yourself as a Member of LIBERTY Dental Plan when

you call the dentist for an appointment. We also suggest that you keep this

material handy and take this information with you when you go to your

appointment. You can then reference benefits and applicable co-payments

which are the out-of-pocket costs associated with your plan.

HOW DO I FILE A CLAIM FORM

There are no claim forms to worry about with your plan. LIBERTY Dental

Plan prepays Plan Primary Care Dentists in advance for covered services

(less applicable co-payments of your plan).

In the case of a specialty referral, we will refer a Member to one of our Plan

specialists. In the instance that there are no Plan specialty providers within a

reasonable distance from your home address, we will refer you to a non-Plan

specialist and benefits will be provided to you as if the specialty provider

was contracted with the Plan. Once a specialty referral is processed, the

Member, the referring Primary Care Dentist who originally submitted the

referral and the Specialist, receive a copy of the approved referral which

includes the services approved, the Member Co-Payment and the amount we

will pay the Specialist (according to their contracted fees). Once the services

have been performed by the Specialist, the Specialist will send the Plan a

claim form and we will pay the Specialist directly for the approved services.

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IS PRIOR BENEFIT AUTHORIZATION NECESSARY

No prior benefit authorization is required in order to receive dental services

from your Primary Care Dentist. The Primary Care Dentist has the authority

to make most coverage determinations. The coverage determinations are

achieved through comprehensive oral evaluations which are covered by your

plan. Your Primary Care Dentist is responsible for communicating the

results of the comprehensive oral evaluation and advising of available

benefits and associated cost.

If your Primary Care Dentist encounters a situation that requires the services

of a specialist, LIBERTY Dental Plan requires a preauthorization

submission, which will be responded to within five (5) business days of

receipt, unless urgent.

If you or your Primary Care Dentist encounter an urgent condition in which

there is an imminent and serious threat to your health, including but not

limited to the potential loss of life, limb, or other major body function, or the

normal timeframe for the decision making process as described above would

be detrimental to your life or health, the response to the request for referral

should not exceed seventy-two (72) hours from the time of receipt of such

information. The decision to approve, modify or deny will be communicated

to the Primary Care Dentist within twenty-four (24) hours of the decision. In

cases where the review is retrospective, the decision shall be communicated

to the enrollee within thirty (30) days of the receipt of the information.

In the event that you need to be seen by a specialist, LIBERTY Dental Plan

does require prior benefit authorization. Your Primary Care Dentist is

responsible for obtaining authorization for you to receive specialty care.

In the instance that there are no contracted specialty providers listed in the

Provider Directory for your county, benefits will be provided to you as if the

specialty providers were contracted with the plan.

If your specialty referral preauthorization is denied or you are dissatisfied

with the preauthorization, please refer to the Grievance Procedure.

EMERGENCY DENTAL CARE

All affiliated LIBERTY Dental Plan Primary Care Dental offices provide

availability of emergency dental care services twenty-four (24) hours per

day, seven (7) days per week.

In the event you require Emergency Dental Care, contact your Primary Care

Dentist to schedule an immediate appointment. For urgent or unexpected

LDP.EOC – Group (09/09)

dental conditions that occur after-hours or on weekends, contact your

Primary Care Dentist for instructions on how to proceed.

If after you contact your Primary Care Dentist and are advised that your

Primary Care Dentist is not available, simply contact any licensed dentist to

receive care. LIBERTY Dental Plan will reimburse you for dental expenses

up to a maximum of seventy-five dollars ($75), less applicable co-payments.

The Plan provides coverage for emergency dental services only if the

services are required to alleviate severe pain or bleeding or if an enrollee

reasonably believes that the condition, if not diagnosed or treated, may lead

to disability, dysfunction or death (e.g. emergency extraction when no other

palliative treatment would suffice and severe gum tissue infection).

Reimbursement for Emergency Dental Care: If the requirements in the

section titled “Emergency Dental Care” are satisfied, LIBERTY Dental Plan

will cover up to $75 of such services per calendar year. If you pay a bill for

covered Emergency Dental Care, submit a copy of the paid bill to:

LIBERTY Dental Plan, Claims Department, P.O. Box 26110, Santa Ana,

CA 92799-6110. Please include a copy of the claim from the provider’s

office or a legible statement of services/invoice. Please forward to LIBERTY

Dental Plan with the following information:

• Your Membership information.

• Individual’s name that received the emergency services.

• Name and address of the dentist providing the emergency

service.

• A statement explaining the circumstances surrounding the

emergency visit.

If additional information is needed, you will be notified in writing. If any

part of your claim is denied you will receive a written explanation of benefits

(EOB) within 30 days of LIBERTY Dental Plan’s receipt of the claim that

includes:

• The reason for the denial.

• Reference to the pertinent Evidence of Coverage

provisions on which the denial is based.

• Notice of your right to request reconsideration of the

denial, and an explanation of the grievance procedures.

Please refer to the Grievance Procedure.

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LIBERTY Dental Plan MEMBER SERVICES DEPARTMENT

LIBERTY Dental Plan Member Services provides toll-free customer service

support Monday through Friday 8:00 a.m. to 5:00 p.m. on normal business

days to assist Members with simple inquiries and resolution of

dissatisfactions. The hearing and speech impaired may use the toll-free

telephone numbers (800) 735-2929 (TTY) or (888) 877-5378 (TTY) to

contact the department. Our toll-free number is (877) 877-1893.

GRIEVANCE PROCEDURE

Introduction

LIBERTY Dental Plan of Florida, Inc., (hereinafter referred to as the Plan)

has a grievance and appeal procedure, which complies with applicable state

and federal law (“The Grievance Procedure”). We will try to resolve any

problems you may encounter over the telephone, but sometimes, additional

steps are necessary. In these cases, we have a Grievance Procedure available

that provides channels for you, or a provider acting on your behalf, to voice

your concerns and have them reviewed and addressed at several levels

within the organization.

Definitions

The following terms, as used in the Grievance section, are defined as

follows:

Adverse Benefit Determination: means a denial of a request for service or

a failure to provide or make payment (in whole or in part) for a benefit. An

Adverse Benefit Determination also includes any reduction or termination of

a benefit, or any other coverage determination that availability of care or

other dental care service does not meet the Plan’s requirements for dental

necessity, appropriateness, dental care setting, or level of care or

effectiveness. As Adverse Benefit Determination based in whole or in part

on dental judgment, includes the failure to cover services because they are

determined to be Experimental, Investigational, cosmetic, not dentally

necessary or inappropriate. The denial of payment for services or charges (in

whole or in part) pursuant to the Plan’s dental contracts with Plan Providers,

where the Member is not liable for such services or charges, are not Adverse

Benefit Determinations.

Authorized Representative: means an individual authorized by the Member

or state law either verbally or in writing, to act on the Member’s behalf in

requesting a dental care service, obtaining claim payment, or participating

during the Grievance process. A Provider may act on behalf of a Member

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without the Member’s express consent when it involves an Urgent

Grievance.

Clinical Peer: means a dental care professional in the same or similar

specialty as typically manages the dental condition, procedure or treatment

under review, who was neither involved in the initial Adverse Benefit

Determination nor a subordinate of such individual. A Clinical Peer may

include a Plan dental director not involved in the initial Adverse Benefit

Determination with the appropriate expertise.

Complaint: means any oral expression or dissatisfaction including

dissatisfaction with the administration, claims practices or provision of

services, which relates to the quality of care provided by a Provider and is

submitted to the Plan or to a State agency. A Complaint is part of the

informal steps of a Grievance procedure and is not part of the formal steps of

a Grievance procedure, unless it is a Grievance as defined herein.

Concurrent Review: means utilization review conducted during a

Member’s course of treatment.

Grievance: means an oral or written Complaint submitted by or on behalf of

a Member to the Plan or a State agency regarding the:

a. Availability, coverage for the delivery, or quality of dental care

services, including a Complaint regarding an Adverse Benefit

Determination made pursuant to utilization review;

b. Claims payment, handling, or reimbursement for dental care

services; or

c. Matters pertaining to the Contractual relationship between a

Member and the Plan.

A Grievance includes both Pre-Service Grievances and Post-Service

Grievances as defined herein. A Grievance does not include a written

Complaint submitted by or on behalf of a Member eligible for a grievance

and appeals procedure provided by the Plan pursuant to Contract with the

Federal Government under Title XVIII of the Social Security Act or other

government programs.

Grievance and Appeals Committee (Committee): means a panel

comprised of a majority of Clinical Peers, established to review second level

Grievances related to Adverse Benefit Determinations. In cases in which

there was a denial of coverage, persons previously involved with the

Adverse Benefit Determination will not be a Member of the Committee but

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may appear before the Committee to present information or answer

questions. The Committee has the authority to bind the Plan to its decisions.

Committee Members, Clinical Peer or otherwise, shall not be subordinate to

those person(s) who made the initial Adverse Benefit Determination, or

those person(s) who made the first level Grievance review decision. The

Committee shall conduct regular meetings on at least a biweekly or monthly

basis (unless there is no business to be transacted at such meeting).

Post-Service Grievance: means a Grievance for which an Adverse Benefit

Determination was rendered for a service that was already provided, and the

Grievance was received within one (1) year after the date of occurrence of

the action that initiated the Grievance, which in the case of a Grievance

involving an Adverse Benefit Determination would be one (1) year from the

date of the Member’s receipt of the initial notice of such Adverse Benefit

Determination.

Pre-Service Grievance: means any Grievance for which a requested service

requires Prior Authorization, an Adverse Benefit Determination was

rendered and the requested service was not provided and the Grievance was

received within one (1) year after the date of occurrence of the action that

initiated the Grievance, which in the case of a Grievance involving an

Adverse Benefit Determination would be one (1) year from the date of the

Member’s receipt of the initial notice of such Adverse Benefit

Determination.

Relevant: means a document, record or other information that:

a. was relied upon in making a benefit determination;

b. was submitted, considered or generated in the course of making the

benefit determination, without regard to whether such document,

record or other information was relied upon in making the benefit

determination;

c. demonstrates compliance with the federal requirements for

safeguards designed to ensure and to verify that benefit claim

determinations were made in accordance with governing plan

documents and that, where appropriate, the plan provisions were

applied consistently with respect to similarly situated Members; or

d. constitutes a statement of policy or guidance with respect to the

Plan concerning the denied treatment option or benefit for the

Member’s diagnosis, without regard to whether such advice or

statement was relied upon in making the benefit determination.

Retrospective Review: means a review, for coverage purposes, of dental

necessity conducted after services were provided to the Member.

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Urgent Grievance: means a Grievance for which a requested service

requires Prior Authorization, or an extension of concurrent care is being

requested; an Adverse Benefit Determination was rendered; the requested

service has not been provided; and the application of non-urgent care

Grievance time frames could seriously jeopardize: (a) the life or health of the

Member; or (b) the Member’s ability to regain maximum function. An

Urgent Grievance is also a Grievance where application of the non-Urgent

timeframes would, in the opinion of a Dentist with knowledge of the

Member’s dental condition, subject the Member to severe pain that could not

be adequately managed without the care or treatment that is being requested.

Claim and Appeal Procedures

There are three types of claims: (1) Pre-Service Claims; (2) Post-Service

Claims; and (3) Claims Involving Urgent Care. It is important that Members

become familiar with the types of claims that can be submitted to LIBERTY

Dental Plan of Florida, Inc. and the time frames and other requirements that

apply.

A. Urgent Care Claims

Initial Claim – An Urgent Care Claim shall be deemed to be filed on the date

received by LIBERTY Dental Plan of Florida, Inc. We shall notify the

Member of Our benefit determination (whether adverse or not) as soon as

possible, taking into account the dental exigencies, but not later than 72

hours after We receive, either orally or in writing, the Urgent Care Claim,

unless the Member fails to provide sufficient information to determine

whether, or to what extent, benefits are covered or payable under the dental

plan. If such information is not provided, LIBERTY Dental Plan of Florida,

Inc. shall notify the Member as soon as possible, but not later than 24 hours

after We receive the Claim, of the specific information necessary to

complete the Claim. The Member shall be afforded a reasonable amount of

time, taking into account the circumstances, but not less than 48 hours, to

provide the specified information. LIBERTY Dental Plan of Florida, Inc.

shall notify the Member of Our benefit determination as soon as possible,

but in no case later than 48 hours after the earlier of:

1. LIBERTY Dental Plan of Florida, Inc.’s receipt of the specified

information; or

2. The end of the period afforded the Member to provide the specified

additional information.

If the Member fails to supply the requested information within the 48-hour

period, the Claim shall be denied. LIBERTY Dental Plan of Florida, Inc.

may notify the Member of its benefit determination orally or in writing. If

LDP.EOC – Group (09/09)

the notification is provided orally, a written or electronic notification shall be

provided to the Member no later than 3 days after the oral notification. A

Member or a provider acting on behalf of the Member, who is not satisfied

with the benefit determination, may appeal an Urgent Care Claim to:

Send in writing to LIBERTY Dental Plan

P.O. Box 26110, Santa Ana, CA 92799-6110,

LIBERTY Dental Plan’s Member Services Department facsimile at:

(888) 334-6034,

Contact a LIBERTY Dental Plan Member Services Representative at:

(877) 877-1893,

B. Pre-Service Claims

Initial Claim – A Pre-Service Claim shall be deemed to be filed on the date

received by LIBERTY Dental Plan of Florida, Inc. We shall notify the

Member of Our benefit determination (whether adverse or not) within a

reasonable period of time appropriate to the dental circumstances, but not

later than 15 days after We receive the Pre-Service Claim. LIBERTY Dental

Plan of Florida, Inc. may extend this period one time for up to 15 days,

provided that LIBERTY Dental Plan of Florida, Inc. determines that such an

extension is necessary due to matters beyond control and notifies the

Member, before the expiration of the initial 15-day period, of the

circumstances requiring the extension of time and the date by which the Plan

expects to render a decision. If such an extension is necessary because the

Member failed to submit the information necessary to decide the Claim, the

notice of extension shall specifically describe the required information, and

the Member shall be afforded at least 45 days from receipt of the notice

within which to provide the specified information.

In the case of a failure by a Member to follow the Plan's procedures for filing

a Pre-Service Claim, the Member shall be notified of the failure and the

proper procedures to be followed in filing a Claim for benefits not later than

five (5) days following such failure. The Plan's period for making the benefit

determination shall be tolled from the date on which the notification of the

extension is sent to the Member until the date on which the Member

responds to the request for additional information. If the Member fails to

supply the requested information within the 45-day period, the Claim shall

be denied. A Member may appeal a Pre-Service Claim as set forth in the

Appeals Section.

LDP.EOC – Group (09/09)

C. Post-Service Claims

Initial Claim – A Post-Service Claim shall be deemed to be filed on the date

received by Health Plan. LIBERTY Dental Plan of Florida, Inc. shall notify

the Member of LIBERTY Dental Plan of Florida, Inc.’s Adverse Benefit

Determination within a reasonable period of time, but not later than 30 days

after the Plan receives the Post-Service Claim. The Health Plan may extend

this period one time for up to 15 days, provided that LIBERTY Dental Plan

of Florida, Inc. determines that such an extension is necessary due to matters

beyond LIBERTY Dental Plan of Florida, Inc.’s control and notifies the

Member, before the expiration of the initial 30-day period, of the

circumstances requiring the extension of time and the date by which the Plan

expects to render a decision. If such an extension is necessary because the

Member failed to submit the information necessary to decide the Post-

Service Claim, the notice of extension shall specifically describe the required

information, and the Member shall be afforded at least 45 days from receipt

of the notice within which to provide the specified information. The Plan's

period for making the benefit determination shall be tolled from the date on

which the notification of the extension is sent to the Member until the date

on which the Member responds to the request for additional information. If

the Member fails to supply the requested information within the 45-day

period, the Claim shall be denied. A Member may appeal a Post-Service

Claim as set forth in the Appeals Section.

D. Appeals

A Member may appeal a Pre-Service Claim or a Post-Service Claim within

180 days of receiving the benefit determination. LIBERTY Dental Plan of

Florida, Inc. shall notify the Member of Our benefit determination on review

as soon as possible, taking into account the dental exigencies, but not later

than 72 hours after the Plan receives the Member’s request. You may submit

an appeal to:

LIBERTY Dental Plan of Florida CONTACT INFORMATION

Send in writing to LIBERTY Dental Plan

P.O. Box 26110, Santa Ana, CA 92799-6110,

LIBERTY Dental Plan’s Member Services Department facsimile at:

(888) 334-6034,

Contact a LIBERTY Dental Plan Member Services Representative at:

(877) 877-1893,

LDP.EOC – Group (09/09)

If you are not satisfied with LIBERTY Dental Plan of Florida, Inc.’s final

decision, you may contact the Florida Department of Financial Services

(FDFS) in writing within 365 days of receipt of the final decision letter. You

also have the right to contact FDFS at any time to inform them of an

unresolved grievance.

The Florida Department of Financial Services

Office of Insurance Regulation, Division of Consumer Services

200 East Gaines Street

Tallahassee, Florida 32399

Telephone 1-877-693-5236

General Information and Procedures

A. Concurrent Care Claims

Any reduction or termination by the Plan of Concurrent Care (other than by

plan amendment or termination) before the end of an approved period of

time or number of treatments shall constitute an Adverse Benefit

Determination. LIBERTY Dental Plan of Florida, Inc. shall notify the

Member of the Adverse Benefit Determination at a time sufficiently in

advance of the reduction or termination to allow the Member to appeal and

obtain a determination on review of the Adverse Benefit Determination

before the benefit is reduced or terminated.

Any request by a Member to extend the course of treatment beyond the

period of time or number of treatments that relates to an Urgent Care Claim

shall be decided as soon as possible, taking into account the dental

exigencies, and LIBERTY Dental Plan of Florida, Inc. shall notify the

Member of the benefit determination, whether adverse or not, within 24

hours after the Plan receives the Claim, provided that any such Claim is

made to the Plan at least 24 hours before the expiration of the prescribed

period of time or number of treatments. Notification and appeal of any

Adverse Benefit Determination concerning a request to extend the course of

treatment, whether involving an Urgent Care Claim or not, shall be made in

accordance with this Grievance Procedure.

B. Initial Claim Determination Notice

LIBERTY Dental Plan of Florida, Inc. shall provide a Member with written

or electronic notification of any Adverse Benefit Determination. The

notification shall set forth, in a manner calculated to be understood by the

Member, the following:

LDP.EOC – Group (09/09)

1. The specific reason(s) for the Adverse Benefit Determination.

2. Reference to the specific dental plan provisions on which the

determination is based.

3. A description of any additional material or information necessary

for the Member to perfect the claim and an explanation of why such

material or information is necessary.

4. A description of LIBERTY Dental Plan of Florida, Inc.’s review

procedures and the time limits applicable to such procedures,

including, when applicable a statement of the Member’s right to

bring a civil action under section 502(a) of the Employee

Retirement Income Security Act of 1974, as amended (ERISA),

following an Adverse Benefit Determination on final review.

5. If an internal rule, guideline, protocol, or other similar criterion was

relied upon in making the Adverse Benefit Determination, either the

specific rule, guideline, protocol, or other similar criterion or a

statement that such rule, guideline, protocol or other similar

criterion was relied upon in making the Adverse Benefit

Determination and that a copy shall be provided free of charge to

the Member upon request.

6. If the Adverse Benefit Determination is based on whether the

treatment or service is Experimental and/or Investigational or not

Medically Necessary, either an explanation of the scientific or

clinical judgment for the determination, applying the terms of the

dental plan to the Member’s dental circumstances, or a statement

that such explanation shall be provided free of charge upon request.

7. In the case of an Adverse Benefit Determination involving an

Urgent Care Claim, a description of the expedited review process

applicable to such Claim.

C. Review Procedures Upon Appeal

LIBERTY Dental Plan of Florida, Inc.’s appeal procedures shall include the

following substantive procedures and safeguards:

1. Member may submit written comments, documents, records, and

other information relating to the claim.

2. Upon request and free of charge, the Member shall have reasonable

access to and copies of any relevant Document.

3. The appeal shall take into account all comments, documents,

records, and other information the Member submitted relating to the

Claim, without regard to whether such information was submitted

or considered in the initial Adverse Benefit Determination.

4. The appeal shall be conducted by an appropriate named fiduciary of

the Plan who is neither the individual who made the initial Adverse

LDP.EOC – Group (09/09)

Benefit Determination nor the subordinate of such individual. Such

person shall not defer to the initial Adverse Benefit Determination.

5. In deciding an appeal of any Adverse Benefit Determination that is

based in whole or in part on a dental judgment, including

determinations with regard to whether a particular treatment, drug,

or other item is Experimental and/or Investigational or not

Medically Necessary, the appropriate named fiduciary shall consult

with a dental care professional who has appropriate training and

experience in the field of medicine involved in the dental judgment.

6. The appeal shall provide for the identification of dental or

vocational experts whose advice was obtained on behalf of the Plan

in connection with a Member’s Adverse Benefit Determination,

without regard to whether the advice was relied upon in making the

Adverse Benefit Determination.

7. The appeal shall provide that the dental care professional engaged

for purposes of a consultation for an Adverse Benefit

Determination, shall be an individual who is neither an individual

who was consulted in connection with the initial Adverse Benefit

Determination that is the subject of the appeal, nor the subordinate

of any such individual.

8. In the case of an Urgent Care Claim, there shall be an expedited

review process pursuant to which:

a. a request for an expedited appeal of an Adverse Benefit

Determination may be submitted orally or in writing by the

Member; and

b. all necessary information, including LIBERTY Dental Plan of

Florida, Inc.’s benefit determination on review, shall be

transmitted between the Plan and the Member by telephone,

facsimile, or other available similarly expeditious methods.

D. Appeal Notification

LIBERTY Dental Plan of Florida, Inc. shall provide a Member with written

or electronic notification of LIBERTY Dental Plan of Florida, Inc.’s benefit

determination upon review.

In the case of an Adverse Benefit Determination, the notification shall set

forth, in a manner calculated to be understood by the Member, all of the

following, as appropriate:

1. The specific reason(s) for the Adverse Benefit Determination.

2. Reference to the specific dental plan provision on which the

Adverse Benefit Determination is based.

LDP.EOC – Group (09/09)

3. A statement that the Member is entitled to receive, upon request,

and free of charge, reasonable access to, and copies of any relevant

Document.

4. A statement describing any voluntary appeal procedures offered by

the Plan and the Member’s right to obtain the information about

such procedures and a statement of the Member’s right to bring an

action under ERISA Section 502(a) when applicable.

5. If an internal rule, guideline, protocol, or other similar criterion was

relied upon in making the Adverse Benefit Determination, either the

specific rule, guideline, protocol, or other similar criterion or a

statement that such rule, guideline, protocol, or other similar

criterion was relied upon in making the Adverse Benefit

Determination and that a copy shall be provided free of charge to

the Member upon request.

6. If the Adverse Benefit Determination is based on whether the

treatment or service is Experimental and/or Investigational or not

Medically Necessary, either an explanation of the scientific or

clinical judgment for the determination, applying the terms of the

dental plan to the Member’s dental circumstances, or a statement

that such explanation shall be provided free of charge upon request.

ARBITRATION

If you or one of your eligible dependents is not satisfied with the results of

LIBERTY Dental Plan’s grievance resolution process, and all the grievance

resolution procedures have been exhausted, the matter can be submitted to

arbitration for resolution. If you, or one of your eligible dependents, believe

that some conduct arising from or relating to your participation as a

LIBERTY Dental Plan Member, including contract or medical liability, the

matter shall be settled by arbitration. The arbitration will be conducted

according to the American Arbitration Association rules and regulations in

force at the time of the occurrence of the grievance (dispute or controversy).

A grievance which is arbitrated pursuant to Chapter 682, Florida Statutes, is

permitted an additional time limitation not to exceed 270 days from the date

the Plan is first notified of the grievance. No Member shall be denied

services or benefits under the Agreement solely on the grounds that he or she

filed a complaint.

PREMIUMS AND CHANGES TO BENEFITS AND PREMIUMS

LIBERTY Dental Plan provides coverage for you under an agreement with

your Plan Sponsor who pays all premiums to us. Your Plan Sponsor will let

you know the amount of premium you must pay, if any. LIBERTY Dental

Plan may change the covered benefits, co-payments, and premium rates from

LDP.EOC – Group (09/09)

time to time. LIBERTY Dental Plan will not decrease the covered benefits or

increase the premium rates during the term of that agreement without giving

notice to your Plan Sponsor at least thirty (30) days before the proposed

change.

MEMBER RESPONSIBILITIES

As a Member, you have the responsibility to:

* Identify yourself to your selected dental office as a LIBERTY Dental

Plan Member

* Treat the Primary Care Dentist, office staff and LIBERTY Dental Plan

staff with respect and courtesy

* Keep scheduled appointments or contact the dental office twenty-four

(24) hours in advance to cancel an appointment

* Cooperate with the Primary Care Dentist in following a prescribed

course of treatment

* Make co-payments at the time of service

* Notify LIBERTY Dental Plan of changes in family status

* Be aware of and follow the organization’s guidelines in seeking dental

care

DEFINITIONS

Benefits and Coverage means those dental care services available under the

Plan Sponsor Group Contract in which a Member is enrolled.

Contract Year means a period of twelve (12) consecutive months as

determined from the effective date of this Group Contract.

Copayment is a specific dollar amount that the Member must pay upon

receipt of covered dental services. Fixed co-payment amounts are listed in

the Co-payment Schedule.

Dental Care Services shall mean and refer to those services, procedures and

operations covered under this Group Contract.

Dental Facilities means those dental centers and dental providers selected

by the Plan to provide dental care services for its Members.

Dental Records Refers to diagnostic aid, intraoral and extra-oral

radiographs, written treatment record including but not limited to progress

notes, dental and periodontal chartings, treatment plans, consultation reports,

or other written material relating to an individual’s medical and dental

history, diagnosis, condition, treatment, or evaluation.

LDP.EOC – Group (09/09)

Dependent includes the following individuals only if they reside or work

within the Plan’s Service Area:

1. The lawful spouse of the Subscriber.

2. Registered domestic partner.

3. The unmarried Dependent Child of a Subscriber, (or in the case of a

newborn child, the Dependent Child of the Subscriber’s covered

Dependents), up to the child’s nineteenth (19

) birthday, or up to

the child’s twenty-fourth (24

) birthday provided the dependent is a

full-time student at an accredited academic institution.

4. A Dependent Child who can be certified to the Plan as incapable of

self-sustaining employment by reason of mental retardation or

physical handicap and is chiefly dependent upon the Subscriber for

support and maintenance. Proof of such incapacity must be

furnished to the Plan by the Subscriber within thirty (30) days of the

request for such proof by the Plan. Recertification of such

incapacity may be required by the Plan, but not more frequently

than once annually.

Emergency Dental Services means those services in a dental office only,

which are required immediately due to an injury or unforeseen condition,

and which provide for the relief of pain or prevent worsening of any dental

condition that would be caused by delay.

Evidence of Coverage means the certificate issued to the Subscriber setting

forth the Plan Administration as well as the Benefits Members are entitled.

Exclusion is any provision of the Plan Sponsor Group Contract whereby

coverage for a specified hazard or condition is entirely eliminated.

Limitation is any provision other than an Exclusion that restricts coverage

under the Plan Sponsor Group Contract.

Experimental means any evaluation, treatment, or therapy which involves

the application, administration or use of procedures, techniques, equipment,

supplies, products or remedies that are considered experimental by the Plan

based on reports, articles or written assessments published by the American

Dental Association or in other authoritative medical and scientific literature

published in the United States.

Full Time Student means a Member who is enrolled and attends an

accredited institution of higher learning in accordance with the institution’s

minimum requirements for full-time student status. A student is considered

full-time during normally scheduled school vacations if he or she is

registered to return to that or a similar institution at the end of the vacation.

LDP.EOC – Group (09/09)

A Member is considered enrolled during summer or holiday vacations when

school is not in session.

Member means any Subscriber or Dependent, who is enrolled under the

Group Contract and is entitled to the Benefits available under the Group

Contract in return for the payment required to be made to the Plan.

Non-Covered Services means and refers to those dental care services not

described in the Co-payment Schedule for which the Plan has no financial

responsibility.

Non-Plan Provider A dentist that has no contract to provide services for the

Plan.

Plan Provider or Dentist refers to a provider of dental services licensed by

the State of Florida to render services to any Member in accordance with the

provisions of the Group Contract in which a Member is enrolled. The

names, locations, hours of service and other information regarding Plan

Providers may be obtained by contacting the Plan or our website,

www.libertydentalplan.com

Plan Sponsor is the organization or company which has entered into an

agreement with the Plan under which Benefits are made available to the

eligible Subscribers and their Dependents.

Premium is the amount payable each month by the Plan Sponsor to obtain

Benefits provider under this Group Contract.

Primary Care Dentist A dentist affiliated with the Plan to provide services

to covered Members of the Plan. The Primary Care Dentist is responsible

for providing or arranging needed dental services.

Service Area means the geographic area in Florida in which the Plan has

contracted with a network of dental providers to provide the services detailed

in this Group Contract. The Service Area is comprised of Miami-Dade,

Broward and Palm Beach counties in the State of Florida and may be revised

from time to time as specified in the Provider Directory.

Specialist refers to Endodontists, Oral Surgeons, Orthodontists, Pediatric

Dentists or Periodontists.

Subscriber is the person whose enrollment form has been accepted by the

Plan in accordance with the eligibility and enrollment requirements of this

Group Contract and for whom the required Premium has been received by

the Plan.

LDP.EOC – Group (09/09)

The Plan means LIBERTY Dental Plan of Florida, Inc.

ANSWERS TO COMMON QUESTIONS

Are my cleanings covered?

Yes. LIBERTY Dental Plan covers routine cleanings (prophylaxis) at your

selected dental office once every 6 months. Some Members may require

more than a “routine” cleaning due to more involved dental needs. When

more frequent cleanings or extensive treatment, such as root planing or

scaling are required, your dentist may charge you in accordance with your

dental plan.

What if I have a pre-existing condition?

Most pre-existing conditions are covered. However, a procedure started

prior to your coverage effective date will not be covered by the Plan.

Are there waiting periods to be met?

No. Once your enrollment become effective, simply make an appointment

with your selected network dentist.

Does the Plan include dental specialists?

Yes. LIBERTY Dental Plan has a contracted network of Dental Specialists.

If specialty is deemed necessary by your Primary Care Dentist, you will be

referred to a specialist after coordinating your needs with your Primary Care

Dentist.

What if I have other dental coverage?

Your LIBERTY Dental Plan network Primary Care Dentist will apply your

reimbursement from any additional coverage you have to your co-payment if

allowable by your other dental plan carrier. This may reduce your out-of-

pocket costs.

How will I know what my co-payment will be?

Refer to your Co-payment Schedule which lists all of the services covered

under your plan. The co-payment schedule is listed by ADA code. If you

have any questions, ask your dentist before you receive services and/or call

the LIBERTY Dental Plan Member Services Department.

LDP.EOC – Group (09/09)

Who do I call if I have a question?

If you have a question about enrollment, talk to your Benefits Manager.

Should you have questions once you become a Member, contact our Member

Services Department.

LIBERTY Dental Plan of Florida, Inc.

P.O. Box 26110

Santa Ana, CA 92799-6110

(877) 877-1893

LDP.EOC – Group (09/09)

NEW MEMBER CONTINUATION OF

CARE INFORMATION

AND PRIVACY STATEMENT

Dear New LIBERTY Dental Plan Member:

If you have been receiving care from a dental care provider, you may have a

right to keep your dental care provider for a designated time period. Please

contact LIBERTY Dental Plan’s Member Services Department at (877) 877-

1893.

You must make a specific request to continue under the care of your current

provider. LIBERTY Dental Plan is not required to continue your care with

that provider if you are not eligible under our policy or if we cannot reach an

agreement with your provider on the terms regarding your care in accordance

with Florida law.

Privacy Statement

We protect the privacy of our Members’ health information as required by

law, accreditation standards and our internal policies and procedures. This

Notice explains our legal duties and your rights as well as our privacy

practices.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT

YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.

We collect, use and disclose information provided by and about you for

health care/dental payment and operations, or when we are otherwise

permitted or required by law to do so.

For Payment: We may use and disclose information about you in managing

your account or benefits, and paying claims for medical/dental care you

receive through your plan. For example, we maintain information about

your premium and deductible payments. We may also provide information

to a doctor/dentist’s office to confirm your eligibility for benefits or we may

ask a doctor/dentist for details about your treatment so that we may review

and pay the claims for your dental care.

LDP.EOC – Group (09/09)

For Health/Dental Care Operations: We may use and disclose medical/dental

information about you for our operations. For example, we may use

information about you to review the quality of care and services you receive,

or to evaluate a treatment plan that is being proposed for you.

We may contact you to provide information about treatment alternatives or

other health-related benefits and services. For example, when you or your

dependents reach a certain age, we may notify you about additional

programs or products for which you may become eligible, such as individual

coverage.

We may, in the case of some group health plans, share limited health

information with your employer or other organizations that help pay for your

Membership in the plan, in order to enroll you, or to permit the plan sponsor

to perform plan administrative functions. Plan sponsors receiving this

information are required, by law, to have safeguards in place to protect it

from inappropriate uses.

As Permitted or Required by Law: Information about you may be used or

disclosed to regulatory agencies, such as during audits, licensure or other

proceedings; for administrative or judicial proceedings; to public health

authorities; or to law enforcement officials, such as to comply with a court

order or subpoena.

Authorization: Other uses and disclosures of protected health information

will be made only with your written permission, unless otherwise permitted

or required by law. You may revoke this authorization, at any time, in

writing. We will then stop using your information. However, if we have

already used your information based on your authorization, you cannot take

back your agreement for those past situations.

Copies and Changes

You have the right to receive an additional copy of this notice at any time.

We reserve the right to change the terms of this notice. A revised notice will

be effective for information we already have about you as well as any

information we may receive in the future. We are required by law to comply

with whatever privacy notice is currently in effect. We will communicate

any changes to our notice through subscriber newsletters, direct mail or our

website, www.libertydentalplan.com

Contact Information

If you want to exercise your rights under this notice, or if you wish to

communicate with us about privacy issues, or to file a complaint with us,

please contact our Member Services Department at (877) 877-1893.